Context: For most of the patients, dengue is a self-limiting viral fever, but in some patients, it results in a life threatening conditioncalled as dengue hemorrhagic fever or dengue shock syndrome. Objective: We attempted to determine the common and atypicalclinical and laboratory features in children suffering from dengue fever, which will help in early diagnosis and management of patientssuffering from dengue infection. Design: Hospital based descriptive, cross-sectional study conducted from January 2014 to December2014. Setting: Tertiary referral teaching hospital. Patients: All patients between 1-month and 12 years admitted in pediatric ward withsymptoms suggestive of dengue and who turn out to be positive for NS1 antigen alone or NS1 and immunoglobulin M antibody againstdengue were included in the study. Data regarding relevant history and clinical examination and outcome and relevant investigationswere collected. Results: Of 250 children included in the study, 145 (58%) were male and 105 (42%) were female. The most commonpresenting complaint was fever (92.8%), followed by abdominal pain (46.4%). The most common clinical sign was pyrexia followedby relative bradycardia (37.6%) and hypotension (26.4%). On laboratory investigation, the most common abnormality detected wasleucopenia (81.6%) followed by thrombocytopenia (69.2%). Conclusion: A high index of suspicion is required on the part of treatingpediatrician to diagnose dengue early and treat accordingly to prevent mortality due to dengue

Chaudhary, Vinod

Khamkar, Anil

Suryawanshi, Amol

Tiwari, Manish

English

Atharva Scientific Publications (E-Jounals)

Chaudhary et al. Clinical profile of dengue
Vol 2 | Issue 3 | Jul - Sep 2015 Indian J Child Health 126
Short Communication
Clinical profile of dengue patients: A hospital based study
Vinod Chaudhary, Anil Khamkar, Manish Tiwari, Amol Suryawanshi
From Department of Pediatrics, Swami Ramanand Teerth Rural Medical College, Ambejogaim, Maharashtra, India
Correspondence to: Dr. Manish Tiwari, Department of Pediatrics, Swami Ramanand Teerth Rural GMC, Ambajogai, Maharashtra, 
India. Phone: +91-9552492393, E-mail: manishtiwari.peds@rediffmail.com
Received – 08 April 2015 Initial Review – 29 April 2015 Published Online – 25 July 2015
Abstract
Context: For most of the patients, dengue is a self-limiting viral fever, but in some patients, it results in a life threatening condition 
called as dengue hemorrhagic fever or dengue shock syndrome. Objective: We attempted to determine the common and atypical 
clinical and laboratory features in children suffering from dengue fever, which will help in early diagnosis and management of patients 
suffering from dengue infection. Design: Hospital based descriptive, cross-sectional study conducted from January 2014 to December 
2014. Setting: Tertiary referral teaching hospital. Patients: All patients between 1-month and 12 years admitted in pediatric ward with 
symptoms suggestive of dengue and who turn out to be positive for NS1 antigen alone or NS1 and immunoglobulin M antibody against 
dengue were included in the study. Data regarding relevant history and clinical examination and outcome and relevant investigations 
were collected. Results: Of 250 children included in the study, 145 (58%) were male and 105 (42%) were female. The most common 
presenting complaint was fever (92.8%), followed by abdominal pain (46.4%). The most common clinical sign was pyrexia followed 
by relative bradycardia (37.6%) and hypotension (26.4%). On laboratory investigation, the most common abnormality detected was 
leucopenia (81.6%) followed by thrombocytopenia (69.2%). Conclusion: A high index of suspicion is required on the part of treating 
pediatrician to diagnose dengue early and treat accordingly to prevent mortality due to dengue.
Key words: Atypical manifestations, Children, Dengue hemorrhagic fever, Dengue infection, Dengue shock syndrome
Dengue is the most rapidly spreading mosquito-borne viral disease in the world. An estimated 50 million dengue infections occur annually, and approximately 2.5 billion 
people live in dengue endemic countries [1]. There are four 
distinct, but closely related serotypes of the virus that cause dengue 
(DEN-1, DEN-2, DEN-3, and DEN-4). However, cross-immunity 
to the other serotypes after recovery is only partial and temporary. 
Subsequent infections by other serotypes increase the risk of 
developing severe dengue [2]. The common clinical features of 
dengue are high grade fever, headache, myalgia, abdominal pain, 
and retro-orbital pain which are similar to other viral illnesses. 
Furthermore, the initial presentation is similar even in patients of 
dengue hemorrhagic fever and dengue shock syndrome. Besides 
this, dengue can also present with atypical clinical features such as 
jaundice, convulsions, and altered consciousness [3]. This study 
was carried out to evaluate the common clinical presentation, 
and to study atypical clinical and laboratory features associated 
with dengue viral infection so that early intervention and better 
case management can be done in those who are likely to have 
complications of dengue viral infection.
METHODS
This hospital based descriptive, cross-sectional study was 
conducted in a tertiary care teaching hospital from January 
2014 to December 2014. Permission from the College Ethical 
Committee was taken, and consent from parents or primary 
caretaker was taken before enrolling the child for study. All the 
patients admitted with symptoms suggestive of dengue such as 
fever, headache, myalgia, abdominal pain etc. were investigated 
for dengue infection. NS1 antigen was done in every patient 
of clinically suspected dengue having at least 24 h of fever 
while enzyme-linked immunosorbent assay (ELISA) dengue 
immunoglobulin M (IgM) and dengue IgG were done only in 
patients with history of fever for more than 1-week. Patients 
between 1-month and 12 years of age and positive for dengue 
ELISA IgM or NS1 antigen with or without IgG were included 
in the study. Patients with age <1-month or more than 12 years 
or positive for dengue IgG alone were excluded from the study.
A detailed clinical history was taken from all the patients 
followed by thorough clinical examination. A complete blood 
count, liver function tests, kidney function tests, X-ray chest, 
and ultrasonography abdomen were done in every patient 
confirmed of dengue. Cerebral spinal fluid (CSF) examination 
was limited to patients showing features of encephalitis. 
Management of patients was done according to World Health 
Organization (WHO) standard guidelines 2009. Patients were 
classified as per guidelines and blood pressure, and heart rate 
were monitored 1 h in patients of dengue hemorrhagic fever and 
Chaudhary et al. Clinical profile of dengue
Vol 2 | Issue 3 | Jul - Sep 2015 Indian J Child Health 127
dengue shock syndrome while 6 h in other patients. Intravenous 
fluids were given as per WHO guidelines and inotropes were 
used in fluid resistant shock. Data were collected with daily 
records of the patient and analyzed using Epi info software.
RESULTS
A total of 250 cases were studied during the course of 
12 months, out of which 145 were male (58%), and 105 (42%) 
were female. The mean age of children in the study was 
5.68 ± 1.59 years. Patients presented with following symptoms 
in decreasing order of frequency - fever (92.8%), abdominal 
pain (46.4%), vomiting (38.8%), headache (36%), dyspnea 
(26%), palpitation (13.6%), and puffiness of face (12.8%), 
epistaxis (9.6%), melena (4.8%), and altered consciousness 
(2%). The findings on clinical examination were pyrexia 
(96.8%), relative bradycardia (37.6%), hypotension (26.4%), 
palpable liver (26.4%), petechial rash (23.2%), abdominal 
tenderness (22.4%), abdominal distension (9.6%), decreased 
air entry (8.8%), and altered consciousness (2%) (Table 1). The 
laboratory findings were leucopenia i.e., total leucocyte count 
below 5000/mm3 (81.6%), thrombocytopenia i.e., platelet 
count <1.5 lacs (69.2%), raised alanine transaminase (58.4%), 
abnormal prothrombin time (6.4%), hyperbilirubinemia 
(6.4%), and pleural effusion (21.6%), and ascites (12.8%) on 
ultrasonography chest and abdomen respectively (Table 2). 
Patients presenting with atypical symptoms were also 
investigated to rule out other infections such as malaria, 
hepatitis A, B, C, typhoid, etc. depending on the presentation. 
Of 250 patients, 240 recovered completely, and there were 10 
deaths, four because of encephalitis and six because of a dengue 
shock syndrome with multi-organ failure. The diagnosis of 
encephalitis was confirmed with the help of CSF analysis and 
serological investigations. Six children developed shock which 
was resistant to fluid and inotropes and progressed to multi 
organ failure.
DISCUSSION
Dengue is now endemic in many countries of the world; 
however, most of the cases are reported from South-East Asia 
and Western Pacific region [2]. In past two decades, India has 
become endemic for dengue and many authors had reported 
periodic epidemic breakouts in various geographical areas in 
India [3-8]. Ours is a tertiary care center located in a rural area 
of Maharashtra, and we faced an epidemic of dengue patients 
in the year 2014. The symptoms and signs of dengue are 
now changing and there are patients presenting with atypical 
symptoms such as jaundice, altered consciousness, upper 
respiratory tract infections, etc.
With the use of standard guidelines for the management 
of dengue patients, the mortality has been decreased. The 
mortality in our study was 4% (10 out of 250) which was 
similar to that reported by other Indian authors [9-12]. Beside 
the common clinical features of fever, abdominal pain, 
headache, hypotension, palpable liver etc., we would like to 
bring attention to other atypical manifestation of dengue such 
as relative bradycardia, altered consciousness, and jaundice. 
Relative bradycardia was found in 37.6% of our patients, 
similar finding of bradycardia was also reported by other 
authors [13,14].
Neurological involvement was found in five patients out 
of whom four patients expired in our study. Neurological 
involvement in form of encephalitis, and Gullian Barre 
syndrome had been formerly reported by other Indian 
authors [9,15]. Elevated liver enzymes is commonly seen in 
dengue patients and this finding was found in 58.4% of our 
patients [9,16,17]. Acute hepatic failure, a rarely reported 
manifestation of dengue hemorrhagic fever was diagnosed in 
ten of our patients. Deranged liver function in dengue infection 
can be a result of the direct effect of the virus on liver cells or the 
unregulated host immune response against the virus. Fulminant 
hepatic failure occurs because of acute severe hepatitis and 
massive necrosis of the liver, causing hepatic encephalopathy 
and even death [18].
A combination of fever, thrombocytopenia and hypotension 
was the most common manifestation which was seen in our study. 
Most of the patients recovered with the help of symptomatic 
Table 1: Frequency of signs in dengue patients
Signs Frequency %
Fever 242 96.8
Relative bradycardia 94 37.6
Hypotension 66 26.4
Palpable liver 66 26.4
Petechial rash 58 23.2
Abdominal tenderness 56 22.4
Abdominal distension 24 9.6
Decreased air entry 22 8.8
Altered consciousness 5 2
Table 2: Abnormal laboratory findings in dengue patients
Investigation Frequency %
Leucopenia 204 81.6
Thrombocytopenia 173 69.2
Serum ALT raised 146 58.4
Abnormal prothrombin time 16 6.4
Hyperbilirubinemia 16 6.4
Ultrasonography
Pleural effusion 54 21.6
Ascites 32 12.8
CSF examination
Encephalitis 5 2
CSF: Cerebral spinal fluid, ALT: Alanine aminotransferase
Chaudhary et al. Clinical profile of dengue
Vol 2 | Issue 3 | Jul - Sep 2015 Indian J Child Health 128
treatment and did not require any platelet or plasma therapy. 
A patient who developed fulminant hepatic failure were given 
plasma therapy as per requirement. Only 18 patients whose 
platelet count was below 25000/mm3 were given platelet 
therapy. Though the role of giving platelet concentrate is 
controversial, we still gave them in patients suffering from 
bleeding and having a platelet count <25,000/mm3 [19,20].
We were unable to classify the type of dengue virus due to 
limited resources and also there is concern regarding dengue 
IgM antibodies detection as it has limitations due to cross-
reactivity between other circulating flaviviruses.
CONCLUSION
The WHO standard guidelines help to classify and manage 
dengue patients rationally, but the management of patients 
presenting with atypical features like encephalopathy and 
hepatic failure are not described. Thus, it becomes essential on 
the part of treating pediatrician to suspect and have knowledge 
of the atypical manifestation of dengue for the early diagnosis 
and proper management of the patient.
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Funding: None; Conflict of Interest: None Stated.
How to cite this article: Chaudhary V, Khamkar A, Tiwari M, 
Suryawanshi A. Clinical profile of dengue patients: A hospital 
based study. Indian J Child Health. 2015;2(3):126-128.


Clinical profile of dengue patients: A hospital based study

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